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DOUGLAS COUNTY SOCIAL SERVICES DEPARTMENT

809 Elm Street, Suite 1186, Alexandria, MN 56308

CONSENT AND REQUEST FOR LAW ENFORCEMENT AND AGENCY RECORDS

I, _____________________________________________________________________________

(Name of Individual - clearly write or print your name)

hereby authorize the County Sheriff’s Office, City Police Department, State Patrol, Department of Natural Resources, Court

Administration, or County Social Services Department to disclose to Douglas County Social Services Department

information regarding an all records check (specific data/records, type of information, appropriate dates): Criminal or

non-criminal type activity including that which reflects violence and drug or alcohol use or abuse.

The individual identified below has applied for or is working in: (Choose one)

”

Adult Foster Care,

Child Foster Care or

Family Day Care Licensing.

The Human Services Licensing Act requires that licensing agencies conduct an applicant background study (investigation)

on all members of the applicant’s household, 13 years of age and older. Records will be requested from the Minnesota

Bureau of Criminal Apprehension and other law enforcement agencies. Information will also be requested from county

social service agencies pertaining to report of maltreatment of children or adults. This information is required in order to

complete an application for licensing under MN Chapter 245C.

I understand that my records are protected under State and Federal confidentiality regulations and cannot be disclosed

without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this

consent at any time and that in any event this consent expires automatically as described below.

This Consent for the Release of Information shall expire one year from the date on which I execute this consent form.

In the alternative, the following date, event, or condition is set forth upon which this Consent expires: One year from

the date signed.

I hereby acknowledge notice that this study will be done and give my consent to any of the above-listed (named)

agencies, offices and departments to release any data of which I am the subject, whether such data is private or public.

I also consent to release of records regarding any present or former adult or child foster care or family day care

licensure or employment in a licensed facility from designated county or agency.

___________________

__________________________________

Date

Signature

__________________________

___________________________________

Signature of Witness

(If authorizing person is minor or incompetent,

signature of parent or guardian.)

List all addresses where you have resided in the last five years (street, city, state, county):

Street

City

State

County

___________Initial Licensure

____________Relicensure

___________Last records check date

*Upon request, this information will be made available in an alternative format.

For Agency Use Only:

Worker_______________________________

Consent And Request For Law Enforcement And Agency Records Form - Douglas County Social Services Department

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